Practice Finance Loan Application for Credit - U.S. Bank

Practice Finance Loan Application for Credit

U.S. Bank Business Development Officer Phone Fax Email

Member FDIC ? 2016 U.S. Bank National Association



Loan Information Form

General Business Information

Legal entity name Address City/State/Zip Federal tax ID # Legal counsel Accountant

Legal counsel phone Accountant phone

DBA Business phone Fax Website

Legal counsel email Accountant email

Business Contact Information

Principal 1 Name Cell phone Email License # Year licensed

Name Cell phone Email License # Year licensed

Principal 2

Name Cell phone Email License # Year licensed

Principal 3

Loan Purpose and Use of Proceeds

c Acquisition c Refinance c Expansion c Start-up c Buy-in c Equipment c Leasehold financing c Shell

Description (attach additional sheets if necessary):

c Purchase price

$

c Equipment

$

c Working capital

$

c Inventory

$

c Tenant/Leasehold improvements

$

c Other:

$

Total Loan Amount $

If buy-in, what % of ownership will you own?

% Anticipated closing date

Are you currently requesting additional funds from any other sources? c Yes c No If yes, please explain:

Loan term Referred by

Loan amortization

Are you a current U.S. Bank customer? Referral phone

c Yes c No Referral email

Practice Information

c General Dentistry

c Orthodontics

c Pediatric Dentistry

c Ophthalmologist

c Endodontics c Other:

c Optometrist

c Veterinary

c Periodontics

The undersigned consents to and authorizes the use of his/her consumer credit report by U.S. Bank or a third party from time to time as may be needed in the credit and collection process and further authorizes banks, trade references and financial institutions the right to release information to us. IMPORTANT CUSTOMER INFORMATION: To help the government fight the funding of terrorism and money laundering activities, Federal law requires financial institutions to obtain, verify and record identifying information on new customers. The personal data requested above will allow us to identify each person signing this application. We may also ask for copies of driver's licenses or other identifying documents.

By providing us with a telephone number for a cellular phone or other wireless device, including a number that you later convert to a cellular number, you are expressly consenting to receiving communications -- including but not limited to prerecorded or artificial voice message calls, text messages, and calls made by an automatic telephone dialing system -- from us and our affiliates and agents at that number. This express consent applies to each such telephone number that you provide to us now or in the future and permits such calls for non-marketing purposes. Calls and messages may incur access fees from your cellular provider.

By providing your email address you will receive emails regarding information about the application process and any information regarding the servicing of this application.

Safeguarding your personal information is important to U.S. Bank. Be sure to use a secure email method that encrypts your email. Please contact your banker with questions related to Secure Email.

You have a right to a copy of any commercial property appraisal report obtained by the Bank in support of your application for credit, provided that you have paid for the appraisal. In order to obtain a copy of your appraisal report, please send a request and forward it to the following address: U.S. Bank, Attn: Portfolio Support, 9918 Hibert St., San Diego, CA 92131-1018 (Fax: 866-940-1244).

If this loan will be secured by commercial real estate, please note: We must hear from you, in writing, no later than 90 days after we notify you about the action taken on your credit application, including notice of an incomplete application. If you withdraw your application, you must make your request for an appraisal report within 90 days of the withdrawal. If you request a copy of your appraisal report, and you have paid for the costs of the appraisal, we will send you a copy at the address shown on your loan application. You are only entitled to receive a copy of the appraisal for purposes of evaluating your pending request for an extension of credit with this Bank.

If this loan will be secured by a first lien on a residential dwelling, please note: U.S. Bank may order an appraisal to determine the property's value and charge you for this appraisal. We will promptly give you a copy of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.

I hereby acknowledge that this authorization does not imply a commitment of the bank to lend money. A commitment to lend, if any, will be set forth in a separate signed agreement.

EQUAL CREDIT OPPORTUNITY ACT NOTICE: The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has the capacity to contract in accordance with the applicable state law); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Protection Act. The federal agency that administers compliance with this law concerning this bank is: Bureau of Consumer Financial Protection, 1700 G Street NW., Washington DC 20006

I acknowledge that I have received and retained a copy of these disclosures. Agreed and accepted:

Borrower's signature

Printed name

Date

Practice name:

Seller's Information (For business acquisition only)

Seller's practice name Seller's name Address Practice transition specialist Population of city where practice is/will be located:

Business phone Cell phone

Practice transition specialist phone Estimated # of doctors practicing in immediate area:

Borrower Detail and Plans (For business acquisition only)

Explain the reason for selecting this practice (including any specifics on the location/area):

Please provide details of the transition plan with the seller(s):

Will the seller(s) or any associate(s) be retained as employees after closing? c Yes c No If yes, please provide their schedules and the anticipated wages they will earn:

Will you provide additional services/procedures? If so, please list: What is the estimated additional annual production from those procedures? $ Will there be any changes made to the staffing, operations, etc.? If so please explain:

Will you bring existing patients to this location? c Yes c No If yes, how many? How do you plan on marketing your new practice?

Expected monthly production from these patients: $

Will you be forming a legal business entity? c Yes c No If yes, please provide the name as it will be shown in the Articles of Formation: Has the lease been negotiated? c Yes c No Lease terms (include the initial lease term and any renewal options provided): Monthly amount: $ What is the condition of your existing equipment? Any planned upgrades or new purchases in the next 12 months? If you own another practice, will the locations be merged? c Yes c No If yes, please provide the location you will merge into: If not, how will you divide your time? (Include specific days and hours at each location) What is the distance between the two locations?

Applicant Professional Information

Monthly personal production as an associate or in your current practice (attach production report/YTD paystub) : $

Average number of patients seen per day:

Insurance:

% Capitation:

% Welfare:

% Cash/Other:

%

Pay structure (complete as applicable): Salary $

(annual) OR Production %

Per day production:

Or per month production:

Is your schedule full? c Yes c No How many practices are you currently working in?

Will you work as an associate outside of this practice? c Yes c No If yes, how much supplemental monthly income will that provide? $

Associate days per week:

Do you have a non-compete contract? c Yes c No If yes,

miles

years

Have you had any actions against your license? c Yes c No If yes, please explain:

Initials: ________________

Practice name:

Relocation of Existing Practice OR Additional Location (Complete if applicable)

c Relocation of existing practice c Additional location

Address of new location:

City:

Explain why you selected this practice location/area:

State:

Zip:

Distance from current location:

miles Total exam rooms:

# Exam rooms to be equipped:

# Exam rooms for doctor use:

Hygiene/assistant use:

Complete the following for Additional Location ONLY:

Population of city where practice is/will be located:

Estimated # of doctors practicing in immediate area:

Total employees:

Doctors:

Assistants:

Hygienists (if applicable):

Front/back office:

Office hours: Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Will you bring existing patients to this location? c Yes c No If yes, how many?

Expected monthly production from these patients: $

How do you plan on marketing your new practice?

Will there be any changes made to the staffing, operations, etc.? If so please explain:

Will you be forming a legal business entity? c Yes c No If yes, please provide the name as it will be shown in the Articles of Formation: Has the lease been negotiated? c Yes c No Lease terms (include the initial lease term and any renewal options provided): Monthly amount: $ What is the condition of your existing equipment? Any planned upgrades or new purchases in the next 12 months? If you own another practice, will the locations be merged? c Yes c No If yes, please provide the location you will merge into: If not, how will you divide your time? (Include specific days and hours at each location)

Expansion of Existing Practice (Complete if applicable)

Please describe the changes you will be making to your office location to expand your business:

Total exam rooms:

# Exam rooms to be equipped:

# Exam rooms for doctor use:

Will there be any changes made to the staffing, operations, etc.? If so please explain:

Hygiene/assistant use:

Will you bring existing patients to this location? c Yes c No If yes, how many? Will you attract new patients to this location? c Yes c No If yes, how many? Will you be forming a legal business entity? c Yes c No If yes, please provide the name as it will be shown in the Articles of Formation: Has the lease been negotiated? c Yes c No Lease terms (include the initial lease term and any renewal options provided): Monthly amount: $ What is the condition of your existing equipment? Any planned upgrades or new purchases in the next 12 months? If you own another practice, will the locations be merged? c Yes c No c N/A If yes, please provide the location you will merge into: If not, how will you divide your time? (Include specific days and hours at each location if applicable) What is the distance between the two locations (if applicable)?

Initials: ________________

Practice name:

General Practice Information (Current practice, complete this section for all locations)

Date practice established:

Length of time owned: years months Was your current practice acquired by you or started up by you? c Acquired c Started

Is the current location real estate owned? c Yes c No If yes: Current lienholder:

Date purchased:

Current loan balance: $

Is the current location leased? c Yes c No If yes: Original lease term:

Renewal Option? c Yes, number of years:

c No

Name/Address of landlord:

Lease expiration date:

Monthly rent: $

Is there room for expansion? c Yes c No Square footage for office space:

Special considerations (e.g., utilities included in rent):

Total exam rooms:

# Exam rooms to be equipped:

# Exam rooms for doctor use:

Hygiene/assistant use:

Total employees:

Doctors:

Assistants:

Hygienists (if applicable):

Front/back office:

Office hours: Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Do clinical hours mirror office hours? c Yes c No If no, please explain the differences:

Types of services provided:

Growth plans for the upcoming year (adding staff, operatories, working hours, services, etc.):

What is the condition of your existing equipment? Any planned upgrades or new purchases in the next 12 months?

How many weeks ahead is the doctor scheduled?

Patient Information

Number of active patients:

(An active patient is defined as a non-emergency patient see/treated within the past 12 months)

Average number of new patients seen per month:

Practice Make-Up

% Receipts from owner:

% Receipts from associate(s):

% Receipts from merchandise:

% Receipts from specialist(s):

Complete the following for Dental Financing ONLY: % Receipts from hygienist(s):

How many weeks ahead is the hygienist scheduled?

Insurance

% Capitation

% Welfare

% Cash/Other

% Adults

% Children

%

Veterinary - Types of Services Provided

Small animal:

% Large animal:

% Equine:

% Grooming/Boarding:

% Other:

%

General Dentistry - Services Referred to Others

Endodontal:

% Periodontal:

% Orthodontal:

% Oral surgery:

% Cosmetic:

%

Veterinary - Services Referred to Others

Please identify what services are referred out (if any):

Optometry - Services Referred to Others

Please identify what services are referred out (if any):

Initials: ________________

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